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F IN 11ME-UP <br /> Y <br /> WELI"TERMIT AF PLICATION MRM UNIT IV <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION (PHS-EHD) <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 RECEN[E[D(209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NOV w 1 2005 <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Stpndards of San Joaquin County Public Health Services <br /> WELL Location /W 7 f1/ l�o•-�n�Yv) �na � �J — GI ( Sd L C1 <br /> ss F0`3H) City Zip <br /> Vty�5 <br /> PROPERTY Owner Dr" ✓ ts ) Address 10,44 W, �I2:- ht( D'-Vi �Lc"2, - <br /> Zip 115'Z076Phone# <br /> C-57 Contractor G7r<, /nI1Address 49140v--z.1Z.., CityYcr�i ip hone# <br /> ze( J'$c-�U <br /> " C <br /> Consultant/Sub Contractor �r��i Address es 5"" 4 �rn� �� f <br /> If! ty _ ic# Phone# yZ0 L>20(D <br /> GIS Coordinates:X Y Township Range Section <br /> — <br /> K TO BE PERFORMED <br /> WOR <br /> NEW WE /BORING(CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER-) 0 DESTRUCTION(choose type below) <br /> 0 SOIL BORING# 0 OVER-BORE <br /> XWELL# 7 � <br /> , A - <br /> `Other: �' 0 PRESSURE GROUT <br /> �r- <br /> COMMENTS: <br /> TYPE OF WELL ^IN/STALLATION TYPE CONSTRUCTION SPECIFICATIONS u <br /> MONITORING jHOLLOW STEM DIA.OF BOREHOLE J dr�MULTIPLE CASINGS?0 YES []NO WELL CASING DIA: <br /> 0 EXTRACTION 0`AIR HAMMER/DRIVEN CASING THICKNESS 5L,1, NO igYPE OF CASING: 0 STEEL APVC 0 OTHER: <br /> 0 VAPOR 0 MUD ROTARY DEPTH OF GROUT SEAL 7�8 TREMIE TYPE TO BE USED: XAUGERS ROSE <br /> 0 AIR SPARGE 0 PUSH POINT GROUT SEAL PUMPED: 0 Yes J 0 No (NOTE: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER APPROX.BORING DEPTH �-d- 7°/ 0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> 0 <br /> OTHER:_0 OTHER CONDUCTOR CASING PROPOSED? (if YES,list specifications here): <br /> COMMENTS: /7 k"--e <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances,State Laws,and Rules <br /> and Regulations of the San Joaquin County. Homeowner or licensed agent's signature certifies the following: "I certify that in the performance of the work <br /> for which this permit is issued,I shall not employ persons subject to WORKERS'COMPENSATION Laws of California." Contractor's hiring or sub- <br /> contracting signature certifies the following: 1 certify that in the performance of the work for which this permit is issued, l shall employ persons subject to <br /> WORKERS'COMPENSATION Laws of California." <br /> CALL THE UNIT IV INSPP� TO 48 WORKING HRS IN ADVANCE/ FOR ALL REQUIRED INSPECTIONS. <br /> Signed x Title/CompanyC� ' c7���+ ��+✓. J <br /> Print Name Date ��- <br /> DEPARTMENT USE ONLY <br /> Application Accepted By Date Issued Area <br /> Grout Inspection By Date Final Inspection By Date_ <br /> Destruction Inspection By Date <br /> COMMENTS/CONDITIONS: <br /> ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO, AMOUNT REMITTED CHECK# REC'D BYDA EJ:PERM1T/SERVICE REQUEST# INVOICE <br /> b l yl PM <br /> 1/1 Q 19nnn <br />